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wisconsir.oepertmentofIndustry, PRIVATE SEWAGE SYSTEM County: <br /> Labo 'and Human Relations INSPECTION REPORT <br /> Safety and Buildings Division <br /> le <br /> (ATTACH TO PERMIT) Sanitary Permit No : <br /> GENERAL INFORMATION c(l <br /> Perm i Holder's Na e: ❑ City ❑ V Ila a To n of: State Plan ID No.: <br /> CST BM Elev.: Insp.BM Elev.: BM Description: Parcel Tax No.: <br /> /00- /�, _ (F AS C S �c�- �t38o - -300 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark , (� (03.13 <br /> Dosing <br /> Aeration Bldg.Sewer ��.58 ���.4 <br /> Holding St/Ht Inlet y.6 C 4 <br /> TANK SETBACK INFORMATION St/Ht Outlet 1100 "k, <br /> TANKTO P/L WELL BLDG. A to ROAD &f4fj1E --� <br /> Ver Intake <br /> Septic �, X5 1 ISi'1 NA Dt-5VrMn1 —G-- <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System <br /> PUMP/ SIPHON INFORMATION Final Grade a <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft Loss <br /> Forcemain Length Dia. Fi Dist To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length ' hes PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS 0 36 a DIM N I N <br /> SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM <br /> LEACHING Manufacturer: <br /> INFORMATION Type O \ CHAMBER Model Num er. <br /> System:CMP v ->J dC�+ 611 OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/M i old ` Distribution Pipe(s)r 1i I x Hole Size 1 x oleSpacing_ Vent To Airintake <br /> I '��� [ C <br /> Length Dia. �'I Length _.�l Dia. Spacing O i � il <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched <br /> Bed/Trench Center Red/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include pcode discrepancies,persons present,etc.) � f <br /> CA V;"1e 0P 7i, _o'�T <br /> Plan revision required? ❑ Yes V(No1 <br /> Use other side for additional information. C� 1 lJ <br /> SBD-6710(R 05191) Date Inspector's Signature Cert.No. <br />